- Email: [email protected]
Psychological therapies for psychosis: a view from the hills
Comment
*J Don Richardson, Lisa King, Jitender Sareen, Jon D Elhai Western University, London, ON N6A 3K7 (JDR), Canada; McMaster University, Hamilton, ON, Canada (JDR); Operational Stress Injury Clinic, Parkwood Hospital, London, ON, Canada (JDR, LK); University of Manitoba, Winnipeg, MB, Canada (JS); Deer Lodge Centre Operational Stress Injury Clinic, Winnipeg, MB, Canada (JS); and University of Toledo, Toledo, OH, USA (JDE) [email protected] We declare no competing interests. 1
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Eekhout I, Reijnen A, Vermetten E, Geuze E. Post-traumatic stress symptoms 5 years after military deployment to Afghanistan: an observational cohort study. Lancet Psychiatry 2015; published online Dec 8. http://dx.doi.org/10.1016/S2215-0366(15)00368-5. Fulton JJ, Calhoun PS, Wagner HR, et al. The prevalence of posttraumatic stress disorder in operation enduring freedom/operation Iraqi freedom (OEF/OIF) veterans: a meta-analysis. J Anxiety Disord 2015; 31: 98–107. Pearson C, Zamorski M, Jan T. Mental health of the Canadian Armed Forces. In: Canada S, ed. Ottawa: Statistics Canada, 2014.
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Marmar CR, Schlenger W, Henn-Haase C, et al. Course of posttraumatic stress disorder 40 years after the Vietnam war: findings from the national Vietnam veterans longitudinal study. JAMA Psychiatry 2015; 72: 875–81. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351: 13–22. Berntsen D, Johannessen KB, Thomsen YD, Bertelsen M, Hoyle RH, Rubin DC. Peace and war: trajectories of posttraumatic stress disorder symptoms before, during, and after military deployment in Afghanistan. Psychol Sci 2012; 23: 1557–65. Rona RJ, Hooper R, Jones M, et al. The contribution of prior psychological symptoms and combat exposure to post Iraq deployment mental health in the UK military. J Trauma Stress 2009; 22: 11–19. Brady K, Killeen T, Brewerton T, Lucerini S. Comorbidity of psychiatric disorders and posttraumatic stress disorder. J Clin Psychiatry 2000; 61 (suppl 7): 22–32. Galatzer-Levy IR, Nickerson A, Litz BT, Marmar CR. patterns of lifetime ptsd comorbidity: a latent class analysis. Depress Anxiety 2013; 30: 489–96. Forbes D, Creamer M, Hawthorne G, Allen N, McHugh T. Comorbidity as a predictor of symptom change after treatment in combat-related posttraumatic stress disorder. J Nerv Ment Dis 2003; 191: 93–99.
Cognitive behavioural therapy for psychosis and family interventions for psychosis are two of the therapies that show the most convincing evidence of achieving meaningful outcomes for individuals with psychosis and their informal carers. 2015 saw several interesting publications describing applications of these therapies in a variety of contexts. It is becoming clearer that the non-affective psychoses are in fact full of affect, which increases the risk and maintenance of episodes through driving individual positive psychosis symptoms. Therefore, attempting to treat affect and its associated symptoms directly is both logical and much valued by service users. Findings from the Worry Intervention Trial1 showed that a six session, manualised treatment for worry was able to improve wellbeing, paranoia, and overall level of psychiatric symptoms in individuals with psychosis, and was well accepted. A pilot trial of individuals with psychosis and insomnia showed large improvements in insomnia (effect size 1·9)2, and there are promising approaches specifically targeting nightmares.3 Findings from another study demonstrated that exposure-based treatments for post-traumatic stress disorder (PTSD) were both safe and efficacious in people diagnosed with psychotic disorder.4 People with psychosis have traditionally been excluded from trials of psychological therapies for PTSD and other emotional disorders, so finding ways to offer effective treatments despite persistent www.thelancet.com/psychiatry Vol 3 January 2016
and distressing positive symptoms of psychosis, is an important development. A further target has been reasoning biases associated with psychosis, on the basis of reports of the positive effects of metacognitive training.5 A proof-of-principle trial of a brief computerised intervention for those with persistent delusions showed improvements in paranoia and reasoning, moderated by negative symptoms and poor working memory.6 This “thinking well” approach is feasible,7 and the intervention is being developed as an interactive app . In the clinic, impressive improvements were reported for a range of meaningful outcomes for consecutive referrals attending a psychological therapies clinic over a 12 year period, all of which were maintained 1 year later.8 An ongoing UK initiative (Improving Access to Psychological Therapies—Severe Mental Illness) has funded pilot sites to increase capacity to offer such interventions, with excellent preliminary outcomes.9 In family intervention for psychosis, the evidence base and our understanding of its long-term effect on patient and carer outcomes was extended by 14 year follow-up data from a cluster randomised controlled trial of family interventions for psychosis in China, which demonstrated improved treatment adherence outcomes for individuals who received the intervention.10 Poor accessibility and limited provision of family interventions for psychosis have driven interest in new approaches, including improved flexibility in
Gustoimages/Science Photo Library
Psychological therapies for psychosis: a view from the hills
For an overview of the interactive app’s design work see http://www.rca.ac.uk/ research-innovation/helenhamlyn-centre/researchprojects/2015-projects/ thinking-well/
9
Comment
For the King’s MOOC on carers for psychosis and schizophrenia see https://www.futurelearn.com/ ourses/caring-psychosisschizophrenia
the timings, settings, and format of how families acquire information and relevant skills, approaches that are self-directed and suitable for larger scale dissemination, and interventions focused on carers themselves. Interventions led by trained family members are also showing promise, for example the positive effect of peer support on family coping styles and illness understanding, which has been shown to be sustained at 6 month follow-up.11 Data from a randomised controlled trial of a 5 week problem-solving bibliotherapy intervention, designed to be completed independently and sampled with carers of individuals with first-episode psychosis, suggested substantial improvements at end of therapy and follow-up in carer skills.12 Finally, digital innovations in the treatment of mental health problems are increasing, with notable applications for addressing family issues. In October, 2015, King’s College London launched the first massive open online course (MOOC) on caring issues for people with psychosis and schizophrenia, with a focus on realtime interaction and reducing carer isolation. The 2 week course attracted more than 16 300 learners from 101 countries, spanning 6 continents. The next step is to determine the effect of these approaches on family reported outcomes. Taking service users’ problems at face value, and demonstrating that people with psychosis—and their carers—can and should be offered the full range of treatments for their distress, is part of the continuing revolution in our understanding of how to improve outcomes for the wide range of difficulties people with psychosis can face.
Elizabeth Kuipers, Juliana Onwumere, *Emmanuelle Peters Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Department of Psychology, London SE5 8AF, UK [email protected] We declare no competing interests. 1
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Freeman D, Dunn G, Startup H, et al. Effects of cognitive behaviour therapy for worry on persecutory delusions in patients with psychosis (WIT): a parallel, single-blind, randomised controlled trial with a mediation analysis. Lancet Psychiatry 2015; 2: 305–13. Freeman D, Waite F, Startup H, et al. Efficacy of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trial. Lancet Psychiatry 2015; 2: 975–83. Sheaves B, Onwumere J, Keen N, Kuipers E. Treating your worst nightmare: a case series of imagery rehearsal therapy for nightmares in individuals experiencing psychotic symptoms. The Cognitive Behavour Therapist 2015; 8: e27. van den Berg DP, de Bont PA, van der Vleugel BM, et al. Prolonged exposure vs eye movement desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a psychotic disorder: a randomized clinical trial. JAMA Psychiatry 2015; 72: 259–67. Moritz S, Andreou C, Schneider BC, et al. Sowing the seeds of doubt: a narrative review on metacognitive training in schizophrenia. Clin Psychol Rev 2014; 34: 358–66. Garety P, Waller H, Emsley R, et al. Cognitive mechanisms of change in delusions: an experimental investigation targeting reasoning to effect change in paranoia. Schizophr Bull 2015; 41: 400–10. Waller H, Emsley R, Freeman D, et al. Thinking Well: a randomised controlled feasibility study of a new CBT therapy targeting reasoning biases in people with distressing persecutory delusional beliefs. J Behav Ther Exp Psy 2015; 48: 82–89. Peters E, Crombie T, Agbedjro D, et al. The long-term effectiveness of cognitive behavior therapy for psychosis within a routine psychological therapies service. Front Psychol 2015; 6: 1658. Jolley S, Garety P, Peters E, et al. Opportunities and challenges in Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI): evaluating the first operational year of the South London and Maudsley (SLaM) demonstration site for psychosis. Behav Res Ther 2015; 64: 24–30. Ran MS, Chan CLW, Ng SM, Guo LT, Xiang MZ. The effectiveness of psychoeducational family intervention for patients with schizophrenia in a 14-year follow-up study in a Chinese rural area. Psychol Med 2015; 45: 2197–204. Duckworth K, Halpern L. Peer support and peer-led family support for persons living with schizophrenia. Curr Opin Psychiatr 2014; 27: 216–21. McCann TV, Cotton SM, Lubman DI. Social problem solving in carers of young people with a first episode of psychosis: a randomized controlled trial. Early Interv Psychiatry 2015; published online Nov 23. DOI:10.1111/eip.12301.
Psychiatric genetics: what’s new in 2015?
David Marchal/Science Photo Library
In 2014, a paper from the Psychiatric Genomics Consortium demonstrated that teamwork generating unprecedented sample sizes allied to rigorous methodology could yield robust findings for schizophrenia on a scale comparable with other medical fields.1 The year 2015 saw rapid escalation in sample sizes across a host of disorders, including those where genome-wide association studies (GWAS) had hitherto have been unsuccessful, such as attention deficithyperactivity disorder, autistic spectrum disorder, and 10
anorexia nervosa. Conference reports suggest we are poised to see breakthroughs in each of those disorders in the coming year. Meanwhile, 2015 saw developments in the genetics of one of the world’s great public health problems, major depressive disorder, in which large heterogeneous GWAS had been unsuccessful. A more homogeneous study of just more than 5000 Chinese women selected for indices of severity identified significant associations at two loci, LHPP and in the vicinity of SIRT1 (encoding sirtuin 1).2 The known role www.thelancet.com/psychiatry Vol 3 January 2016
*J Don Richardson, Lisa King, Jitender Sareen, Jon D Elhai Western University, London, ON N6A 3K7 (JDR), Canada; McMaster University, Hamilton, ON, Canada (JDR); Operational Stress Injury Clinic, Parkwood Hospital, London, ON, Canada (JDR, LK); University of Manitoba, Winnipeg, MB, Canada (JS); Deer Lodge Centre Operational Stress Injury Clinic, Winnipeg, MB, Canada (JS); and University of Toledo, Toledo, OH, USA (JDE) [email protected] We declare no competing interests. 1
2
3
Eekhout I, Reijnen A, Vermetten E, Geuze E. Post-traumatic stress symptoms 5 years after military deployment to Afghanistan: an observational cohort study. Lancet Psychiatry 2015; published online Dec 8. http://dx.doi.org/10.1016/S2215-0366(15)00368-5. Fulton JJ, Calhoun PS, Wagner HR, et al. The prevalence of posttraumatic stress disorder in operation enduring freedom/operation Iraqi freedom (OEF/OIF) veterans: a meta-analysis. J Anxiety Disord 2015; 31: 98–107. Pearson C, Zamorski M, Jan T. Mental health of the Canadian Armed Forces. In: Canada S, ed. Ottawa: Statistics Canada, 2014.
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8
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Marmar CR, Schlenger W, Henn-Haase C, et al. Course of posttraumatic stress disorder 40 years after the Vietnam war: findings from the national Vietnam veterans longitudinal study. JAMA Psychiatry 2015; 72: 875–81. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351: 13–22. Berntsen D, Johannessen KB, Thomsen YD, Bertelsen M, Hoyle RH, Rubin DC. Peace and war: trajectories of posttraumatic stress disorder symptoms before, during, and after military deployment in Afghanistan. Psychol Sci 2012; 23: 1557–65. Rona RJ, Hooper R, Jones M, et al. The contribution of prior psychological symptoms and combat exposure to post Iraq deployment mental health in the UK military. J Trauma Stress 2009; 22: 11–19. Brady K, Killeen T, Brewerton T, Lucerini S. Comorbidity of psychiatric disorders and posttraumatic stress disorder. J Clin Psychiatry 2000; 61 (suppl 7): 22–32. Galatzer-Levy IR, Nickerson A, Litz BT, Marmar CR. patterns of lifetime ptsd comorbidity: a latent class analysis. Depress Anxiety 2013; 30: 489–96. Forbes D, Creamer M, Hawthorne G, Allen N, McHugh T. Comorbidity as a predictor of symptom change after treatment in combat-related posttraumatic stress disorder. J Nerv Ment Dis 2003; 191: 93–99.
Cognitive behavioural therapy for psychosis and family interventions for psychosis are two of the therapies that show the most convincing evidence of achieving meaningful outcomes for individuals with psychosis and their informal carers. 2015 saw several interesting publications describing applications of these therapies in a variety of contexts. It is becoming clearer that the non-affective psychoses are in fact full of affect, which increases the risk and maintenance of episodes through driving individual positive psychosis symptoms. Therefore, attempting to treat affect and its associated symptoms directly is both logical and much valued by service users. Findings from the Worry Intervention Trial1 showed that a six session, manualised treatment for worry was able to improve wellbeing, paranoia, and overall level of psychiatric symptoms in individuals with psychosis, and was well accepted. A pilot trial of individuals with psychosis and insomnia showed large improvements in insomnia (effect size 1·9)2, and there are promising approaches specifically targeting nightmares.3 Findings from another study demonstrated that exposure-based treatments for post-traumatic stress disorder (PTSD) were both safe and efficacious in people diagnosed with psychotic disorder.4 People with psychosis have traditionally been excluded from trials of psychological therapies for PTSD and other emotional disorders, so finding ways to offer effective treatments despite persistent www.thelancet.com/psychiatry Vol 3 January 2016
and distressing positive symptoms of psychosis, is an important development. A further target has been reasoning biases associated with psychosis, on the basis of reports of the positive effects of metacognitive training.5 A proof-of-principle trial of a brief computerised intervention for those with persistent delusions showed improvements in paranoia and reasoning, moderated by negative symptoms and poor working memory.6 This “thinking well” approach is feasible,7 and the intervention is being developed as an interactive app . In the clinic, impressive improvements were reported for a range of meaningful outcomes for consecutive referrals attending a psychological therapies clinic over a 12 year period, all of which were maintained 1 year later.8 An ongoing UK initiative (Improving Access to Psychological Therapies—Severe Mental Illness) has funded pilot sites to increase capacity to offer such interventions, with excellent preliminary outcomes.9 In family intervention for psychosis, the evidence base and our understanding of its long-term effect on patient and carer outcomes was extended by 14 year follow-up data from a cluster randomised controlled trial of family interventions for psychosis in China, which demonstrated improved treatment adherence outcomes for individuals who received the intervention.10 Poor accessibility and limited provision of family interventions for psychosis have driven interest in new approaches, including improved flexibility in
Gustoimages/Science Photo Library
Psychological therapies for psychosis: a view from the hills
For an overview of the interactive app’s design work see http://www.rca.ac.uk/ research-innovation/helenhamlyn-centre/researchprojects/2015-projects/ thinking-well/
9
Comment
For the King’s MOOC on carers for psychosis and schizophrenia see https://www.futurelearn.com/ ourses/caring-psychosisschizophrenia
the timings, settings, and format of how families acquire information and relevant skills, approaches that are self-directed and suitable for larger scale dissemination, and interventions focused on carers themselves. Interventions led by trained family members are also showing promise, for example the positive effect of peer support on family coping styles and illness understanding, which has been shown to be sustained at 6 month follow-up.11 Data from a randomised controlled trial of a 5 week problem-solving bibliotherapy intervention, designed to be completed independently and sampled with carers of individuals with first-episode psychosis, suggested substantial improvements at end of therapy and follow-up in carer skills.12 Finally, digital innovations in the treatment of mental health problems are increasing, with notable applications for addressing family issues. In October, 2015, King’s College London launched the first massive open online course (MOOC) on caring issues for people with psychosis and schizophrenia, with a focus on realtime interaction and reducing carer isolation. The 2 week course attracted more than 16 300 learners from 101 countries, spanning 6 continents. The next step is to determine the effect of these approaches on family reported outcomes. Taking service users’ problems at face value, and demonstrating that people with psychosis—and their carers—can and should be offered the full range of treatments for their distress, is part of the continuing revolution in our understanding of how to improve outcomes for the wide range of difficulties people with psychosis can face.
Elizabeth Kuipers, Juliana Onwumere, *Emmanuelle Peters Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Department of Psychology, London SE5 8AF, UK [email protected] We declare no competing interests. 1
2
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Freeman D, Dunn G, Startup H, et al. Effects of cognitive behaviour therapy for worry on persecutory delusions in patients with psychosis (WIT): a parallel, single-blind, randomised controlled trial with a mediation analysis. Lancet Psychiatry 2015; 2: 305–13. Freeman D, Waite F, Startup H, et al. Efficacy of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trial. Lancet Psychiatry 2015; 2: 975–83. Sheaves B, Onwumere J, Keen N, Kuipers E. Treating your worst nightmare: a case series of imagery rehearsal therapy for nightmares in individuals experiencing psychotic symptoms. The Cognitive Behavour Therapist 2015; 8: e27. van den Berg DP, de Bont PA, van der Vleugel BM, et al. Prolonged exposure vs eye movement desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a psychotic disorder: a randomized clinical trial. JAMA Psychiatry 2015; 72: 259–67. Moritz S, Andreou C, Schneider BC, et al. Sowing the seeds of doubt: a narrative review on metacognitive training in schizophrenia. Clin Psychol Rev 2014; 34: 358–66. Garety P, Waller H, Emsley R, et al. Cognitive mechanisms of change in delusions: an experimental investigation targeting reasoning to effect change in paranoia. Schizophr Bull 2015; 41: 400–10. Waller H, Emsley R, Freeman D, et al. Thinking Well: a randomised controlled feasibility study of a new CBT therapy targeting reasoning biases in people with distressing persecutory delusional beliefs. J Behav Ther Exp Psy 2015; 48: 82–89. Peters E, Crombie T, Agbedjro D, et al. The long-term effectiveness of cognitive behavior therapy for psychosis within a routine psychological therapies service. Front Psychol 2015; 6: 1658. Jolley S, Garety P, Peters E, et al. Opportunities and challenges in Improving Access to Psychological Therapies for people with Severe Mental Illness (IAPT-SMI): evaluating the first operational year of the South London and Maudsley (SLaM) demonstration site for psychosis. Behav Res Ther 2015; 64: 24–30. Ran MS, Chan CLW, Ng SM, Guo LT, Xiang MZ. The effectiveness of psychoeducational family intervention for patients with schizophrenia in a 14-year follow-up study in a Chinese rural area. Psychol Med 2015; 45: 2197–204. Duckworth K, Halpern L. Peer support and peer-led family support for persons living with schizophrenia. Curr Opin Psychiatr 2014; 27: 216–21. McCann TV, Cotton SM, Lubman DI. Social problem solving in carers of young people with a first episode of psychosis: a randomized controlled trial. Early Interv Psychiatry 2015; published online Nov 23. DOI:10.1111/eip.12301.
Psychiatric genetics: what’s new in 2015?
David Marchal/Science Photo Library
In 2014, a paper from the Psychiatric Genomics Consortium demonstrated that teamwork generating unprecedented sample sizes allied to rigorous methodology could yield robust findings for schizophrenia on a scale comparable with other medical fields.1 The year 2015 saw rapid escalation in sample sizes across a host of disorders, including those where genome-wide association studies (GWAS) had hitherto have been unsuccessful, such as attention deficithyperactivity disorder, autistic spectrum disorder, and 10
anorexia nervosa. Conference reports suggest we are poised to see breakthroughs in each of those disorders in the coming year. Meanwhile, 2015 saw developments in the genetics of one of the world’s great public health problems, major depressive disorder, in which large heterogeneous GWAS had been unsuccessful. A more homogeneous study of just more than 5000 Chinese women selected for indices of severity identified significant associations at two loci, LHPP and in the vicinity of SIRT1 (encoding sirtuin 1).2 The known role www.thelancet.com/psychiatry Vol 3 January 2016